This was a regional (North East) event run by AHSN and NG CCG and was focusing on ‘transfers of care’. It was a great opportunity to show how our vanguard work is a crucial part of the system for older people’s care. It also allowed us to showcase how we are actively aligning vanguard work with our local system community and neighbourhood care model.
I was asked to think about the ‘system’ necessary to support the transfers of care for older people. The audience was wide, a mixture of providers and commissioners across the NHS and wider ‘care’ system. My aim was to explore with the audience how different parts of the health and care system contribute to transfers of care. We looked at the ‘key’ areas of ‘challenge’ and ‘opportunity’ for improving quality and experience. We explored ‘frailty’ – with the identification of frailty and subsequent ‘needs’ assessment being a crucial part of a successful ‘transfer of care’. We also looked at measuring ‘best practice’ across a system linked with outcomes as part of new commissioning landscape. Finally, the presentation finished with an example of how Newcastle Gateshead Vanguard work was being aligned to the wider out of hospital model of care – People, Communities and Care.